Patellar Tendinopathy

Normal Anatomy

• Distal pole of patella

• Superior facet tibial tuberosity

Normal Anatomy

• Collagen– Parallel– Crimped– Tensile strength

• Ground Substance– Proteoglycans (PG)– Glycosaminoglycan (GAG)

tail– Hydrophillic– Compressive strength

Mechanism of Injury

• Tendon is over or under loaded

• Results in some tissue degradation

• Repair is attempted

• Insufficient time or load

• Tendon degenerationCook and Purdam, 2008

Mechanism of Injury

Magnusson et al, 2008

Pathophysiology

• Increased tenocyte activity

• Increase ground substance

• Collagen deterioration

• Neovascularisation

• Nerve sprouting

Pathophysiology

• Reactive– Inflammatory markers– Minimal tissue

degradation– ?Reversible structural

change

• Degenerative– Disorganised tendon– Decrease Type 1 collagen– Increase Type 3 collagen

Maffuli et al, 2000

Pathophysiology

Cook et al, 2001

Pathophysiology

• Cortical changes may be present

• “All or nothing” response to loading

• Neural compromise

• Radiculopathy

PathophysiologyTranscranial Magnetic Stimulation

Pathophysiology

Reactive Degenerative

Symptoms Irritable Stable

History Recent load change Stable load

Age Young Older

US Reactive (acute)Degenerative (acute on chronic)

Degenerative likely

Pathology Reversible Irreversible

Principles Settle tenocytes Stimulate tenocytes

Associated Pathologies

• Inferior pole– PFPS– Fat pad– Sinding-Larsen-Johnansson Disease

• Tibial Tuberosity– Osgood-Schlatter’s Disease– Infrapatellar bursa– Pes anserinus

Subjective

• Usually atraumatic• Local pain• Night pains• ?History of lower limb injury• Reported change in loading• Lag between load and symptoms• Some initial pain, reduces and returns after

exercise

Objective

• Observation– Spine alignment– Tendon thickening– Muscle bulk

• ROM– Full ROM

• Strength– Kinetic chain

Malliaras and Cook, 2011

Objective

• Neural– Femoral nerve

• Palpation– Local tenderness– Pinpoint location

Objective

• Movement Patterns– Single leg stance– Squat and single leg

squat

• Biomechanics– Femoral torsion– Tibial torsion

Special Tests

Standing Active Quads Sign– Palpate in standing– Locate point tenderness– Unilateral stand– 30 degrees knee flex– Decrease symptoms on

palpation

Passive Ext-Flex Sign– Palpate in supine– Leg in extension– Locate Point tenderness– Passive 90 degrees knee

flex– Decrease symptoms on

palpation

London Hospital Test

Further Investigation

• US Scan

• MRI

• Hypo-echoic more likely pain

Should always be a clinical diagnosis!

Malliaras et al, 2010

Management

• Reduce pain

• Increase load tolerance

• Improve function

• Time

• ?Improve structure

Conservative - Management

Load Modification• Reactive

– Address load– Correct biomechanics

• Degenerative– Correct biomechanics– Loading strategies– Isometric– Conc/Ecc

Conservative

• Isometric– 4-5 reps 3-4 per day– 40-60 sec hold– High load– Little or no pain

• Mechanotransduction• Minimal movement• Tendon Loading– No matrix stimulation

Conservative

• Eccentric– Leg extension– Leg press– Split Squat– Squat

• S&C

• Sport specific

Conservative - Management

• Adjuncts– Acupuncture– Deep transverse frictions– Joint mobilisations– Shockwave– Soft tissue massage– Taping and strapping

Surgical - Management

• Injections– High Volume– Steroid– PRP

• Debridement

• Shockwave

References• Birch HL. (2007). Tendon matrix composition and turnover in relation to

functional requirements. Int J Exp Path. 88; 241-248

• Cook JL, Khan KM, Purdam CR. (2001). Conservative treatment of patellar tendinopathy. Physical Therapy in Sport. 2; 54-65

• Cook JL, Purdam CR. (2008). Is tendon pathology and continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med. 43; 409-416

• Maffuli N, Ewen S, Waterston S, Reaper J, Barrass V. (2000). Tenocytes from ruptured and tendinopathic achilles tendons produce greater quantities of type III collagen than tenocytes from normal achilles tendon. Am J Sports Med. 28; 499-505

References• Magnusson SP Langburg H, Kjaer M. (2010).The pathogenesis of

tendinopathy: balancing the response to loading. Nat Rev Rheumatol. 6; 262–268

• Malliaras P, Purdam C, Maffuli N, Cook J. (2010). Temporal sequence of greyscale ultrasound changes and their relationship with neurovascularity and pain in the patellar tendon. Br J Sports Med. 44; 944-947

• Malliaras P, Cook J. (2011). Changes in anteroposterior patellar tendon diameter support a continuum of pathological changes. Br J Sports Med. 45; 1048-1051

• Warden SJ. (2003). Patellar tendinopathy. Clinical Sports Medicine. 22; 743-759